Suturing device with split arm and method of suturing tissue

ABSTRACT

A device for suturing an opening in a tissue, having an elongated shaft, at least two arms movable to a deployed positioning which the arms are non-perpendicular to the shaft, the arms having needle receiving portions; and needles advanceable longitudinally along the shaft toward the needle receiving portions, the needles exiting through side walls of the shaft at a location proximal to the arms.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.13/615,530, filed Sep. 13, 2012, which is a continuation of U.S. patentapplication Ser. No. 12/247,012, filed Oct. 7, 2008, now U.S. patentapplication Ser. No. 8,419,753, which is a Divisional application ofU.S. patent application. Ser. No. 10/746,210, filed Dec. 23, 2003, nowU.S. Pat. No. 7,449,024 the disclosures of which are each incorporatedherein by this reference.

BACKGROUND 1. Background and Relevant Art

The present invention relates generally to apparatus and methods for thesuturing of body lumens. More particularly, the present inventionrelates to techniques for percutaneous closure of arterial and venouspuncture sites, which are usually accessed through a tissue tract.

A number of diagnostic and interventional vascular procedures are nowperformed translumenally. A catheter is introduced to the vascularsystem at a convenient access location and guided through the vascularsystem to a target location using established techniques. Suchprocedures require vascular access, which is usually established duringthe well-known Seldinger technique, as described, for example, inWilliam Grossman's “Cardiac Catheterization and Angioplasty,” 3.sup.rdEd., Lea and Febiger, Philadelphia, 1986, incorporated herein byreference. Vascular access is generally provided through an introducersheath, which is positioned to extend from outside the patient body intothe vascular lumen.

When vascular access is no longer required, the introducer sheath isremoved and bleeding at the puncture site stopped. One common approachfor providing hemostasis (the cessation of bleeding) is to applyexternal force near and upstream from the puncture site, typically bymanual or “digital” compression. This approach suffers from a number ofdisadvantages. It is time consuming, frequently requiring one-half houror more of compression before hemostasis is assured. Additionally, suchcompression techniques rely on clot formation, which can be delayeduntil anticoagulants used in vascular therapy procedures (such as forheart attacks, stent deployment, non-optical PTCA results, and the like)wear off. This can take two to four hours, thereby increasing the timerequired before completion of the compression technique. The compressionprocedure is further uncomfortable for the patient and frequentlyrequires analgesics to be tolerable. Moreover, the application excessivepressure can at times totally occlude the underlying blood vessel,resulting in ischemia and/or thrombosis. Following manual compression,the patient typically remains recumbent from four to as much as twelvehours or more under close observation so as to assure continuedhemostasis. During this time renewed bleeding may occur, resulting inblood loss through the tract, hematoma and/or pseudoaneurysm formation,as well as arteriovenous fistula formation. These complications mayrequire blood transfusion and/or surgical intervention.

The incidence of complications from compression-induced hemostasisincreases when the size of the introducer sheath grows larger, and/orwhen the patient is anticoagulated. It is clear that the compressiontechnique for arterial closure can be risky, and is expensive andonerous to the patient. Although the risk of complications can bereduced by using highly trained individuals, dedicating such personnelto this task is both expensive and inefficient. Nonetheless, as thenumber and efficacy of translumenally performed diagnostic andinterventional vascular procedures increases, the number of patientsrequiring effective hemostasis for a vascular puncture continues toincrease.

To overcome the problems associated with manual compression, the use ofbioabsorbable fasteners or sealing bodies to stop bleeding haspreviously been proposed. Generally, these approaches rely on theplacement of a thrombogenic and bioabsorbable material, such ascollagen, at the superficial arterial wall over the puncture site. Whilepotentially effective, this approach suffers from a number of problems.It can be difficult to properly locate the interface of the overlyingtissue and the adventitial surface of the blood vessel. Locating thefastener too far from that interface can result in failure to providehemostasis, and subsequent hematoma and/or pseudo-aneurysm formation.Conversely, if the sealing body intrudes into the arterial lumen,intravascular clots and/or collagen pieces with thrombus attached canform and embolize downstream, causing vascular occlusion. Also, thrombusformation on the surface of a sealing body protruding into the lumen cancause a stenosis, which can obstruct normal blood flow. Other possiblecomplications include infection, as well as adverse reaction to thecollagen or other implant.

A more effective approach for vascular closure has been proposed in U.S.Pat. Nos. 5,417,699, 5,613,974; and PCT published Patent Application No.PCT/US96/10271 filed on Jun. 12, 1996, the full disclosures of which areincorporated herein by reference. A suture-applying device is introducedthrough the tissue tract with a distal end of the device extendingthrough the vascular puncture. One or more needles in the device arethen used to draw suture through the blood vessel wall on opposite sidesof the puncture, and the suture is secured directly over the adventitialsurface of the blood vessel wall to provide highly reliable closure.

While a significant improvement over the use of manual pressure, clamps,and collagen plugs, certain design criteria have been found to beimportant to successful suturing to achieve vascular closure. Forexample, it is highly beneficial to properly direct the needles throughthe blood vessel wall at a significant distance from the puncture sothat the suture is well anchored in the tissue and can provide tightclosure. It is also highly beneficial to insure that the needledeployment takes place when the device is properly positioned relativeto the vessel wall. The ease of deployment and efficacy of the procedurecan further be enhanced by reducing the cross-section of that portion ofthe device, which is inserted into the tissue tract and/or the vesselitself, which may also allow closure of the vessel in a relatively shortamount of time without imposing excessive injury to the tissue tract orvessel.

For the above reasons, it would be desirable to provide improveddevices, systems, and methods for suturing vascular punctures. The newdevice should have the capability of delivering a pre-tied knot to anincision site. It would be particularly beneficial if these improveddevices provided some or all of the benefits while overcoming one ormore of the disadvantages discussed above.

DESCRIPTION OF THE BACKGROUND ART

U.S. Pat. Nos. 5,700,273, 5,836,956, and 5,846,253 describe a woundclosure apparatus and method in which needles are threaded with sutureinside a blood vessel. U.S. Pat. No. 5,496,332 describes a wound closureapparatus and method for its use, while U.S. Pat. No. 5,364,408describes an endoscopic suture system.

U.S. Pat. No. 5,374,275 describes a surgical suturing device and methodof use, while U.S. Pat. No. 5,417,699 describes a device and method forthe percutaneous suturing of a vascular puncture site. An instrument forclosing trocar puncture wounds is described in U.S. Pat. No. 5,470,338,and a related device is described in U.S. Pat. No. 5,527,321. U.S. Pat.No. 5,507,757 also describes a method of closing puncture wounds.

U.S. Pat. No. 6,245,079, describes another suturing system, the completedisclosure of which is incorporated herein by reference in its entiretyfor all purposes.

BRIEF SUMMARY

The present invention provides a device for suturing an opening in atissue. In various embodiments, the device includes an elongated shaftwith a pair of deployable arms. When deployed, these arms arenon-perpendicular to the longitudinal axis of the shaft. In oneembodiment, the arms are independently deployable. In one embodiment, afirst arm is an anterior arm which is deployed by being rotated lessthan 90 degrees to the longitudinal axis of the shaft, and the secondarm is a posterior arm which is deployed by being rotated more than 90degrees to the longitudinal axis of the shaft. A pivot stop may beprovided on the elongated shaft to limit rotation of the arms when theyreach their fully deployed position. Each of the first and second armsmay include a needle receiving portion thereon. Needles may be advancedlongitudinally along the shaft toward the needle receiving portions onthe arms. The needles may exit through a side wall of the shaft at alocation proximal to the arms.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a cross-sectional view of a suturing system with its distalend inserted through an arterial wall. (FIG. 1 corresponds to FIG. 41 ofU.S. Pat. No. 6,245,079).

FIG. 2 is a cross-sectional view of the device of FIG. 41 in a partiallydeployed state. (FIG. 2 corresponds to FIG. 42 of U.S. Pat. No.6,245,079).

FIG. 3 is cross-sectional view of the device of FIG. 1 with the sutureclasp member fully deployed. (FIG. 3 corresponds to FIG. 47 of U.S. Pat.No. 6,245,079).

FIG. 4A is a front plan view of the present invention in its compactposition (i.e. prior to deployment).

FIG. 4B is a left side elevation view of the present invention prior todeployment.

FIG. 5A is a front plan view of the present invention after deployment.

FIG. 5B is a right side elevation view of the present invention afterdeployment.

FIG. 6 is an illustration of the system of FIG. 5B deployed at a nonperpendicular angle relative to the axis of a blood vessel while thefirst and second arms 610 and 620 are positioned longitudinally alongthe inside of the wall of blood vessel.

FIG. 7 is an embodiment of the present split arm invention,incorporating a pre-tied knot.

DETAILED DESCRIPTION

FIGS. 1, 2 and 3 show a suturing device corresponding to the suturingdevice described in U.S. Pat. No. 6,245,079, the complete disclosure ofwhich is incorporated herein by reference in its entirety for allpurposes. Specifically, FIGS. 1, 2, and 3 correspond to FIGS. 41, 42 and47 of U.S. Pat. No. 6,245,079.

Referring to FIG. 1, distal portion of the suturing device 520 ispositioned in femoral artery 16. Suturing device 520 comprises a sutureintroducer head 522 attached to the distal end of a hollow elongatedbody 514. Suture clasp member 500 and the needles 546 reside in the samelongitudinal space. In other words, the needles 546 share the samehousing as the suture clasp member 500 (while they are all in theirretracted state), but are higher up (proximally) in the suturing device520 than the suture clasp member 500. Flexible needles 546 bend outward,away from the axis of the device 520, when in the extended position (asshown in FIG. 3).

As shown in FIGS. 2 and 3, the suture introducer head 522 has two needleports or apertures 510 formed therein (one per needle 546) proximal tothe suture clasp arms 524. Each needle port includes a needle guidingportion 512 (“needle guide”), in the form of an outwardly curved grooveor channel, which guides the corresponding needle 546 along a particularpath. The needle guides 512 may be formed within the suture introducerhead 522 (as shown in FIG. 1) as part of a mold, or may be separatepieces (not shown) that are inserted into the suture introducer head 522during manufacture.

Bleed back is accomplished by the hole 540 at the distal end 504 of thesuture introducer head 522, the suture clasp arm apertures 508 and anyother openings in the suture introducer head 522. The direction of bloodflow for bleed back is shown by the dashed arrows in FIG. 1.

Suture 40 closes the artery vessel opening 26 transverse to the flow ofblood. Proper insertion of the needles 546 reduces the risk of damage tothe vessel walls 22, 506.

Suturing device 520 includes a single, resilient suture clasp member 500attached to the actuating rod 50. The suture clasp member 500 comprisesa center or hinge portion 542 and two suture clasp arms 524 (one foreach needle 546). Each suture clasp arm 524 has a suture clasp 544 atthe end thereof.

The hinge portion 542 of the suture clasp member 500 acts as a “livinghinge” because it has a memory which causes the member 500 to return toa partially open, unretracted position (FIG. 2) when a force (appliedvia rod 50) is released. This can be seen in FIGS. 1 and 2. In FIG. 2,the suture clasp member 500 is deployed in the artery 16 in itspredisposed (relaxed or natural) position. In FIG. 1, the suture claspmember 500 is retracted into the suture introducer head 522 in itscompressed (stressed or tensed) position. The arms 524 are moved to theretracted position by applying a distal force to the actuator rod 50,which causes the arms to contact deflection surfaces 518 (FIG. 2).

This suture clasp member 500 is preferably composed of a resilient shapememory material such as NITINOL, but may alternatively be composed ofanother material with spring-like characteristics, such as plastic,spring steel, stainless steel or any variations thereof. Further, thesuture clasp member 500 could be composed of two arms that are hingedlyconnected to the actuating rod 50 without the use of a resilient hinge.

Needles 546 are flexible and preferably made from a material with shapememory, such as SUPERFLEX NITINOL. Alternatively, the needles 546 may becomposed of spring steel, surgical stainless steel or any variationthereof.

When the needles 546 are advanced distally and come in contact with theneedle insertion guides 512, the needle insertion guides cause theneedles 546 to bend radially outward. The needles 546 also preferablyfurther bend slightly (radially outward) when they come in contact withthe angled surfaces 545 of the suture clasp arms 524, as shown in FIG.3. When the needles 546 are retracted into the needle lumens 516, theyresume a straight configuration as a result of their resiliency.

The proximal portion of the suturing device 520 preferably includes ahandle which allows the physician to externally operate the suture clasparms 524 and the needles 546 inside the blood vessel 16. This handlepreferably has three actions: a first action in which the actuating rod50 applies a proximal force to the hinge portion 542 to deploy andmaintain arms 524 in a fully outward position (FIG. 3); a second actionto advance the needles 546 distally (FIG. 3) and pull the needles 546back proximally using one or more springs; and a third action in whichthe actuating rod 50 applies a distal force to the hinge portion 542 toretract the arms 524 (FIG. 1).

The locked position of the suture clasp arms 524 provides a stable baseor foundation for holding the looped ends of the suture 40 while theneedles 546 come in contact with the suture clasp arms 524 and capturethe suture 40. The suture clasp arms 524 are locked in the lockedposition by the proximal force of the actuating rod 50, the stationaryinside edges 536 of the apertures 508 and the protrusions 528 at the‘elbow’ end of each arm 524 (FIG. 3). Specifically, when the sutureclasp arms 524 become substantially parallel with each other (i.e., eacharm 524 is at an angle of approximately 90 degrees from the actuatingrod 50), the protrusions 528 at the ‘elbow’ end of each arm 524 comeinto contact with each other and prevent the arms 524 from bending anyfurther than the configuration shown in FIG. 3. The suture clasp member500 cannot open any farther, even when the needles 546 are inserteddistally and come in contact with the suture clasp arms 524. Theprotrusions 528 prevent the suture clasp member 500 from movingunintentionally (opening any farther) when the needles 546 come incontact with the suture clasp arms 524. This reduces the risk of thelooped ends of the suture 40 being accidentally displaced from thesuture clasps 544 when the needles 546 engage the suture clasps 544.Thus, the combination of forces asserted by the actuating rod 50, theproximal inside edges 536 of the aperture 508 and the two protrusions528 sustain the suture clasp arms 524 in a rigid, locked position tofacilitate the proper removal of the suture looped ends from the sutureclasps 544.

The slits of the suture clasps 544 are angled in a proximal, radiallyinward direction. Thus, the face of the looped ends of the suture 40face in a proximal, radially inward direction. In this configuration,there is less chance of the looped ends of the suture 40 falling off thesuture clasps 544 improperly or prematurely. When the needles 546 engagethe suture clasp arms 524, the only direction the looped ends may moveis in a proximal, radially inward direction, which is in the oppositedirection of the inserted needles 546. When the needles 546 retractproximally (as shown in FIG. 3), the looped ends reliably fall into thesuture catches 38 of the needles 546. It is the proximal movement of theneedles 546 which causes the suture catches 38 on the needles 546 tocatch the looped ends of the suture 40. This configuration does not relyon a radially outward tension in the looped ends to fasten the loopedends onto the suture catches 38 when the needles 546 are inserteddistally.

The description of each of introducer sheath 6, suture catches 38,needle incisions 248, pivot pin 502 and lumen 530 is provided byreference to identically numbered elements in U.S. Pat. No. 6,245,079.

A first important disadvantage of the suturing system illustrated inFIGS. 1, 2 and 3 is that both of the arms 524 deploy to a position thatis exactly 90 degrees from the axis of suturing device. This is becauseprotrusions 528 abut one another when suture clasp 500 is fully opened(as shown in FIG. 3). As described above, and in U.S. Pat. No.6,245,079, it is an advantage of the system of FIGS. 1 to 3 that arms542 of suture clasp 500 do not open more than 90 degrees to reduce therisk of the looped ends of the suture 40 being accidentally displacedfrom the suture clasps 544 when the needles 546 engage the suture clasps544.

Unfortunately, this is particularly problematic when suturing inside ablood vessel, since it may be preferred to enter the blood vessel at anon-perpendicular (e.g.: oblique) angle. In the system of FIGS. 1 to 3,the distal end of the suturing device must therefore be extended to somedistance into the blood vessel during operation.

A first feature of the embodiments of the present split arm suturingdevice is that each of its arms may be extended to different angles fromthe body of the device. In various embodiments, such angles arenon-perpendicular to the longitudinal axis of the suturing device. Moreparticularly, one arm may be extended to a position less than 90 degreesto the body of the device, whereas the other arm may be extended to aposition more than 90 degrees to the body of the device.

A second feature of various embodiments of the present split armsuturing device is that each of its arms may be extended one at a time.

Separately, or taken together, these two features of the presentinvention provide a system which may be conveniently positioned to enterthe blood vessel at a non-perpendicular angle, thus minimizing thepotential for damage to the blood vessel, while ensuring properplacement of the suture. Thus, an operator can gain better access tosmaller arteries and maintain a smaller elbow height, as compared to thesuturing device of FIGS. 1 to 3. Thus, the present independentlyoperable split arm suturing device offers significantly increasedflexibility to the operator, as compared to the suturing device of FIGS.1 to 3.

Referring first to FIGS. 4A and 4B, split arm suturing device 600 isshown prior to deployment (i.e. in its compact position). Suturingdevice 600 has moveable arms 610 and 620 which can be pivoted relativeto the longitudinal axis L of suturing device 600. Arms 610 and 620 maybe independently moveable. As will be shown herein, when deployed, arm610 will preferably be deployed in an anterior direction, and arm 620will preferably be deployed in a posterior direction.

Anterior arm 610 and posterior arm 620 may be made independentlymoveably by any of a variety of mechanisms, all keeping within the scopeof the present invention. In the illustrated embodiments, arms 610 and620 are independently actionable (i.e. moveable between compact anddeployed positions) by flexible linkages in tension or compression. Itis to be understood, however, that any push pull wire, gear or camsystem, or any other suitable actuation system may be used, all keepingwithin the scope of the present invention. As illustrated in FIG. 5B,arm 610 may be deployed by moving linkage 612, and arm 620 may bedeployed by moving linkage 622. Specifically, by pulling linkage 612proximally, anterior arm 610 rotates around pivot 614 until finger 611contacts pivot stop 625. Similarly, by pulling linkage 622 proximally,posterior arm 620 rotates (in an opposite direction) around pivot 624until stop surface 621 contacts pivot stop 625. Specifically, anteriorarm 610 moves through angle A1 when moved from its compact position toits deployed position. Referring to FIG. 6, posterior arm 620 movesthrough angle A2 when moved from its compact position to its deployedposition. As can be appreciated, by instead distally pushing linkages612 and 622, arms 610 and 620 can be moved back to their compact (i.e.:non-deployed) position.

After deploying arms 610 and 620 (by retracting linkages 612 and 622) afirst needle 616, and a second needle 626 can then be advanced towardthe distal ends of arms 610 and 620, respectively to retrieve oppositeends of a suture 40. In various embodiments, needles 616 and 626 arelongitudinally advanceable along the shaft 601 of suturing device 600,and exit through side wall openings 630 and 640 at locations proximal tothe arms 610 and 620, respectively.

FIG. 6 shows an embodiment of the present invention deployed at a nonperpendicular angle relative to the axis of a blood vessel BV while theanterior arm 610 and posterior arm 620 are positioned longitudinallyalong the inside of the wall of blood vessel BV. Specifically, thedistal end of suturing device 600 is positioned though a puncture P inblood vessel BV.

Needles 616 and 626 are advanced longitudinally along through shaft, andexit through side wall openings 630 and 640, and then puncture throughrespective needle punctures NP1 and NP2 in the wall of blood vessel BV.Thereafter, needles 616 and 626 can be retracted pulling the oppositeends of suture 40 upwardly through punctures NP1 and NP2 in the wall ofblood vessel BV.

In various embodiments, cuffs 618 and 628 can be provided at oppositeends of suture 40 to ensure that the distal ends of needles 616 and 626connect securely onto the opposite ends of suture 40. Variousembodiments of cuffs, links, barbs, fasteners, or combinations thereofare also contemplated to ensure that the distal ends of needles 616 and626 connect securely onto the opposite ends of suture 40. Thus, cuffs618 and 628 may be any of a variety of different designs.

Referring again to FIGS. 5A and 5B, by moving linkages 612 and 622independently, and to different distances, arms 610 and 620 may beindependently deployed to different angles relative to the longitudinalaxis L of the body of suturing device 600. For example, as shown inFIGS. 5A and 5B, arm 610 may be rotated less than 90 degrees from theaxis of the elongated body of suturing device 600, whereas 620 may berotated more than 90 degrees from the axis of the elongated body ofsuturing device 600.

As shown in FIG. 6, this advantageously allows the elongated body ofsuturing device 600 to be positioned through tissue Tract T (enteringthrough skin S) at a non-perpendicular angle relative to the axis of ablood vessel BV while the first and second arms 610 and 620 arepositioned longitudinally along the inside of the wall of blood vesselBV for placement of the suture axially along the blood vessel and acrossthe puncture. Specifically, suturing device 600 can be used to positionthe ends of suture 40 at locations such that they can be retrieved byneedles 616 and 626, and pulled upwardly through needle punctures NP1and NP2, respectively.

In various embodiments, the elongated body of suturing device 600 issufficiently rigid to maintain alignment of needles 616 and 626 witharms 610 and 620, respectively. As can be seen, in various embodiments,needles 616 and 626 may be of different lengths.

As shown in FIG. 7, a pre-tied knot feature may also be incorporatedinto suturing device 600. The pre-tied knot may initially be positionedwrapped around an exterior surface of the suturing device. Specifically,a length of suture 40 having opposite ends and a bight 680 of suturetherebetween may be provided with bight 680 being disposed around anexterior surface of device 600. Bight 680 may alternately bepre-arranged around one of the needles and within the elongated body.

Bight 680 includes one or more loops of suture that form a pre-tied knot690 when one or more ends of suture 40 are advanced through bight 680.Bight 680 of suture may be prearranged in any of several configurationson the device. For example, bight 680 may be pre-arranged so as todefine a square knot, a clinch knot or a variety of known or newsurgical knots.

In various embodiments, suture 40 is arranged to provide the pre-tiedknot 680 that automatically travels down from the shaft of the device600 where it is stored prior to delivery to the tissue wall. In variousembodiments, to distinguish the ends of suture 40, during deployment,the ends of the suture may be distinguished from each other by changingthe color of one end (e.g. with dye), providing an attachment on one end(e.g. shrink wrap tubing, a bead, etc.) or with the suture itself (e.g.tying a knot in one end).

In accordance with the present invention, suture bight 680 is disposedon the outside surface of device 600, as shown. In this embodiment,suture 40 does not pass through the interior of the device. It should beunderstood, however, that other embodiments of the invention may includesuture 40 and bight 680 stored inside the shaft or housing of the devicerather than on the outside. Yet other configurations may includedetachable tips and connecting filaments to enable a pre-tied knot.

After needles 616 and 626 retrieve opposite ends of suture 40, and pullthese ends of the suture back up through the center of bight 680 todefine the pre-tied knot 690, and arms 610 and 620 are rotated back to anon-deployed position, device 600 may be removed from the patient.Pre-tied knot 690 will slide down the shaft, resulting in a suturepattern in which the opposite ends of suture 40 pass upwardly throughthe center of bight 680.

While embodiments and applications of this invention have been shown anddescribed, it will be apparent to those skilled in the art that variousmodifications are possible without departing from the scope of theinvention. It is, therefore, to be understood that within the scope ofthe appended claims, this invention may be practiced otherwise than asspecifically described.

What is claimed:
 1. An apparatus for suturing a puncture in a bloodvessel, comprising: an elongated body; a first arm movably connected tothe elongated body, the first arm being selectively movable between aretracted position and an extended position, the first arm beingpositioned in a generally anterior direction relative to the elongatedbody in the extended position; a second arm movably connected to theelongated body, the second arm being selectively movable between aretracted position and an extended position, the second arm beingpositioned in a generally posterior direction relative to the elongatedbody in the extended position; at least one needle being selectivelyextendable from the elongated body to engage at least one needlereceiving portion in at least one of the first arm and the second arm.2. The device of claim 1, wherein the arms are independently deployable.3. The device of claim 1, further comprising: a first deployment linkageconnected to the first arm; and a second deployment linkage connected tothe second arm.
 4. The device of claim 3, wherein each deploymentlinkage comprises a member that is pulled proximally to deploy one ofthe arms, and is pushed distally to move the arm to the compactposition.
 5. The device of claim 3, wherein each deployment linkagecomprises a wire.
 6. The device of claim 1, further comprising: a pivotstop on the distal end of the elongated shaft, wherein the pivot stoplimits rotation of the arms when they reach the deployed position. 7.The device of claim 6, wherein the at least two arms comprise ananterior arm and a posterior arm, wherein the anterior arm has anextension portion that contacts the pivot stop when the anterior arm isin its deployed position, and wherein the posterior arm has a stopsurface that contacts the pivot stop when the posterior arm is in itsdeployed position.
 8. An apparatus for suturing a puncture in a bloodvessel, comprising: an elongated body; a first arm movably connected tothe elongated body, the first arm being selectively movable between aretracted position and an extended position, the first arm beingrotatable from the retracted position to the extended position through afirst angle; a second arm movably connected to the elongated body, thesecond arm being selectively movable between a retracted position and anextended position, the second arm being rotatable from the retractedposition to the extended position through a second angle, the secondangle being greater than the first angle; at least one needle beingselectively extendable from the elongated body to engage at least oneneedle receiving portion in at least one of the first arm and the secondarm.
 9. The apparatus of claim 8, wherein one needle is adapted to beconnected to a first end of a length of suture, the suture having asecond end and a bight between the first and second ends, the bightbeing prearranged on the elongate body to define a pre-tied knot whenthe first end of the suture passes through the bight.
 10. The apparatusof claim 8, wherein the elongated body is sufficiently rigid to maintainalignment of the first needle with the first arm and the second needlewith the second arm, respectively.
 11. The apparatus of claim 8, whereinthe first and second end portions of the suture have cuffs disposedthereon.
 12. An apparatus for suturing a puncture in a blood vessel,comprising: an elongated body having a longitudinal axis; a first armmovably connected to the elongated body, the first arm being selectivelymovable between a retracted position and an extended position, the firstarm being oriented at a non-perpendicular angle relative to thelongitudinal axis when the first arm is in the extended position; asecond arm movably connected to the elongated body, the second arm beingselectively movable between a retracted position and an extendedposition, the second arm being oriented at a non-perpendicular anglerelative to the longitudinal axis when the first arm is in the extendedposition, the second arm also being oriented generally parallel to thefirst arm when the first arm and second arm are in the extendedpositions; at least one needle being selectively extendable from theelongated body to engage at least one needle receiving portion in atleast one of the first arm and the second arm.
 13. The device of claim12, wherein the at least two arms comprise: a first arm that is pivotedless than 90 degrees to the longitudinal axis of the elongated shaftwhen in the deployed position; and a second arm that is pivoted morethan 90 degrees to the longitudinal axis of the elongated shaft when inthe deployed position.
 14. The device of claim 12, further comprising: afirst deployment linkage connected to the first arm; and a seconddeployment linkage connected to the second arm.
 15. The device of claim14, wherein each deployment linkage comprises a member that is pulledproximally to deploy one of the arms, and is pushed distally to move thearm to the compact position.
 16. The device of claim 14, wherein eachdeployment linkage comprises a wire.
 17. The device of claim 12, furthercomprising a pivot stop on the distal end of the elongated shaft,wherein the pivot stop limits rotation of the arms when they reach thedeployed position.
 18. The device of claim 17, wherein the at least twoarms comprise an anterior arm and a posterior arm, wherein the anteriorarm has an extension portion that contacts the pivot stop when theanterior arm is in its deployed position, and wherein the posterior armhas a stop surface that contacts the pivot stop when the posterior armis in its deployed position.
 19. An apparatus for suturing a puncture ina blood vessel, comprising: an elongated body having a first side wallopening and a second side wall opening, the second sidewall openingbeing longitudinally offset from the first side wall opening; a firstarm movably connected to the elongated body, the first arm beingselectively movable between a retracted position and an extendedposition, the first arm being positioned in a generally anteriordirection relative to the elongated body in the extended position; asecond arm movably connected to the elongated body, the second arm beingselectively movable between a retracted position and an extendedposition, the second arm being positioned in a generally posteriordirection relative to the elongated body in the extended position; afirst needle being selectively extendable from the elongated bodythrough the first side wall opening and toward the first arm when thefirst arm is in the extended position; and a second needle beingselectively extendable from the elongated body through the second sidewall opening and toward the second arm when the second arm is in theextended position.
 20. The apparatus of claim 19, wherein the elongatedbody has a longitudinal axis, the first needle extends from the firstside wall opening at a first angle relative to the longitudinal axis,and the second needle extends from the second side wall opening at asecond angle relative to the longitudinal axis, the second angle beinggreater than the first angle.